[Hepatitis B prevalence and risk factors in Morocco]. / Prévalence de l'infection par le virus de l'hépatite B et l'évaluation des facteurs de risque au Maroc.

AIM: The aim of this study was to determine the prevalence of hepatitis B and the risk factors in Morocco. STUDY DESIGN: A total number of 16,634 individuals were screened for HBsAg using the Murex HBsAg Version 3 assay and were interviewed using a structured standard questionnaire to collect information about risk factor. RESULTS: Two hundred seventy-six subjects were positive for HBsAg, the prevalence of HBV infection was 1.66%. Using a structured standard questionnaire we reported that sexual behaviours (43.84%) are among the main risk factors for HBV transmission. CONCLUSION: This study indicates that the prevalence of HBsAg in Morocco is currently estimated at 1.66% in the active population. The risk factors for HBV infection identified here indicate that prevention is the most cost-effective method for successfully controlling HBV infection, so vaccination remains the best way to control this infection and its related complications.

[Thyroid function after hypofractionated adjuvant radiotherapy for localized breast cancer]. / Fonction thyroïdienne après une radiothérapie adjuvante hypofractionnée pour un cancer du sein localisé.

PURPOSE: We aimed to evaluate the impact on the thyroid function of hypofractionated adjuvant radiotherapy of localized breast cancer. MATERIAL AND METHOD: This was a prospective study, including 50 patients with breast cancer treated by hypofractionated adjuvant radiation, only half of whom received radiotherapy on the supraclavicular region. The analysis focused on clinical, dosimetric and biological data collected through periodic dosing of thyroid hormones. RESULTS: The incidence of hypothyroidism was 4% of the patients. The multivariate correlation analysis showed a significant association between initial thyroid volume, volume receiving 50Gy, 40Gy and 30Gy and the incidence of hypothyroidism, no statistical link was found between the bilateral breast, chemotherapy, hormone therapy and the type of surgery and the incidence of radiation-induced hypothyroidism. CONCLUSION: Although hypofractionation theoretically exposes the thyroid gland to late radiotherapy complications, radiation-induced dysthyroidism remains a complication underestimated by clinicians, and in the absence of prevention and treatment guidelines, it is necessary to delineate systematically the thyroid gland, to try to minimize as much as possible the doses received by this organ, and to monitor the thyroid function by periodic serum assays.

Schwannoma of the external auditory canal: An exceptional site.

INTRODUCTION: Schwannomas are benign solitary neural tumours that are only exceptional located in the external auditory canal, as only a few cases have been reported in the literature. CASE REPORT: We report a case of schwannoma of the external auditory canal in an 18-year-old man admitted for an isolated mass of the initial segment of the right external auditory canal visible to the naked eye, obstructing all of the external auditory meatus. Computed tomography of the temporal bone showed an isolated mass of the external auditory canal. Management of this patient consisted of biopsy-excision of the mass, histological examination of which confirmed a schwannoma of the external auditory canal. DISCUSSION: Although rare, the possibility of a nerve tumour of the external auditory canal should always be considered. These tumours may be isolated or may occur in the context of von Recklinghausen's disease. The clinical presentation in the external auditory canal may correspond to recurrent otitis externa secondary to obstruction of the canal by the tumour, as in the case reported here. The definitive diagnosis must be based on the results of histological and immunohistochemical examination.

Subacute bacterial endocarditis presenting as polymyalgia rheumatica or giant cell arteritis.

OBJECTIVE: To report on several patients with subacute bacterial endocarditis who were initially presumed, incorrectly, to have polymyalgia rheumatica or giant cell arteritis. METHODS: We report 3 cases of subacute streptococcal endocarditis mimicking giant cell arteritis in 2 cases and polymyalgia rheumatica in one. We reviewed the literature through Medline search of French and English-language articles published between 1966 and 2005 and found 5 similar cases. RESULTS: Shoulder and/or pelvic girdle pain was associated with neck or back pain in all patients. Scalp tenderness, bilateral jaw pain, amaurosis fugax were present in 2 patients. One patient had no fever. Two patients were treated with corticosteroids with initial good clinical response in one. Appropriate antibiotic therapy resulted in the rapid disappearance of rheumatic complaints in 2 patients and achieved a definitive cure of endocarditis in all cases. CONCLUSION: Rheumatologic symptoms may hinder the correct diagnosis of infective endocarditis in patients who present with a clinical picture suggesting polymyalgia rheumatica or giant cell arteritis. In such cases, blood cultures should be systematically drawn.

Acute celiac trunk thrombosis revealed by biliary peritonitis.

Acute thrombosis of the celiac trunk is a very uncommon condition, which is a life-threatening emergency. The clinical presentation is highly variable depending on the extent of the ischemic territory. We report a case of biliary peritonitis related to an acute thrombosis of the celiac trunk. This case highlights the role of abdominal computed tomography in the diagnosis of acute upper abdominal pain.

Amyloid goiter as the initial manifestation of systemic amyloidosis due to familial mediterranean fever with homozygous MEFV mutation.

We describe a case of amyloid goiter revealing a systemic amyloidosis secondary to familial Mediterranean fever (FMF) with homozygous MEFV mutation, and we review the literature. A 45-year-old euthyroid Sephardic man, known to suffer from FMF, developed a goiter with cold nodule, after which a subtotal thyroidectomy was performed. Histologic evaluation revealed diffuse AA amyloid deposition without any associated thyroid neoplasia. At that time, no other organ was found to be affected by amyloidosis. Colchicine and levothyroxine were prescribed. Eight years later, the patient presented with a rapidly growing neck enlargement. He reported that he had discontinued colchicine therapy 2 years earlier. The serum thyrotropin (TSH) and calcitonin levels were normal. Renal, digestive, and salivary gland biopsies confirmed the presence of systemic AA amyloidosis. Despite the reintroduction of colchicine, the onset of compressive symptoms led to the completion of the total thyroidectomy. The histopathology again demonstrated amyloid deposition, and excluded a malignant neoplasm. Nine cases of amyloid goiter associated with FMF have been reported in the literature; none of them had an amyloid goiter as the first manifestation of systemic amyloidosis. To our knowledge, this is the first case of FMF in which an amyloid goiter preceded the development of secondary systemic amyloidosis. The cessation of colchicine therapy may have played a role in local relapse and the secondary spread of amyloid deposits.

[Efficacy of colchicine in recurrent acute idiopathic pericarditis]. / Efficacité de la colchicine dans les péricardites aiguës récidivantes idiopathiques.

Acute idiopathic pericarditis is complicated by recurrence in 15 to 30% of cases. The preventive treatment of recurrences is not well codified. Aspirin, non-steroidal anti-inflammatory drugs and corticoids are the commonest prescribed treatments. The objective of this study was to assess the value of colchicine in the prevention of recurrences of acute idiopathic pericarditis. Twenty-eight cases of recurrent acute pericarditis (2 episodes, 1 month between each episode) admitted to a department of internal medicine between 1989 and 1999 were reviewed. Analysis was concentrated on the 13 idiopathic forms. The subjects were 7 women and 6 men with an average age of 41 years (10-62) at the time of the first episode of acute pericarditis. These 13 patients were treated with colchicine (1 to 2 mg/day) after failure of conventional treatment (aspirin 13/13, NSAID 13/13, steroids 9/13 and pericardiocentesis 3/13). Ten patients were followed up regularly (6 months after starting colchicine) and were improved with respect to number, duration and intensity of their recurrences. The average duration of colchicine therapy was 17 +/- 14 months (6-48). Progressive withdrawal of NSAID and steroids was obtained in 8/10 cases. The authors conclude that colchicine is useful in the prevention of recurrence of acute pericarditis. It may be proposed as treatment of choice, especially in the idiopathic forms.

[Central nervous system involvement in hepatitis C virus infection]. / Atteinte neurologique centrale et infection par le virus de l'hépatite C.

Few well-documented cases of central nervous system involvement in patients with hepatitis C virus infection have been reported. We describe three patients (two men and one woman) with cerebral involvement (ischemia and/or hemorrhage). Hepatitis C virus infection was confirmed in all patients by polymerase chain reaction detection of hepatitis C virus RNA. These three cases document the occurrence of central nervous system involvement in patients with hepatitis C virus infection and mixed cryoglobulinemia. Cerebral involvement may be the initial manifestation of hepatitis C virus infection.

[Systemic sarcoidosis during interferon-alpha therapy for chronic hepatitis C virus infection]. / Sarcoïdose systémique au cours d'un traitement par interféron alpha pour une hépatite chronique virale C.

A 62-year-old white woman with chronic hepatitis C virus infection was diagnosed with systemic sarcoidosis during treatment with interferon-alpha. Seventeen cases of sarcoidosis associated with interferon treatment have been reported, with only 8 inpatients with chronic hepatitis C virus infection. Our patient, with no past history of sarcoidosis, developed subcutaneous sarcoid nodules, arthritis, uveitis, pneumonitis and heart involvement two months after she was started on treatment with interferon-alpha. Her symptoms resolved when she began corticosteroid therapy and interferon-alpha was stopped. This case report suggests that exogenous interferon-alpha may trigger or contribute to the development of this multisystem granulomatous disorder in which interferon-gamma and CD4 + T-lymphocyte are mainly involved. Patients should be monitored during and following interferon-alpha therapy, since the autoimmune diseases induced by interferon therapy do not always improve after cessation of treatment.

[Edematous syndrome revealing an exudative lymphocytic gastritis: efficacy of omeprazole]. / Syndrome oedémateux révélant une gastrite lymphocytaire exsudative: efficacité de l'oméprazole.

Lymphocytic gastritis is characterized by intense lymphocytic infiltration of gastric epithelium. Excessive gastric protein loss is uncommon. We describe the case of a 49-year-old white woman suffering from generalized edema and abdominal pain. She had severe serum hypoproteinemia, hypoalbuminemia and hypogammaglobulinemia. There was no renal, cardiac or hepatic origin of protein loss, and no protein-losing enteropathy. Endoscopic examination showed diffuse varioliform gastritis and histology confirmed lymphocytic gastritis with > 30% intraepithelial lymphocytes without Helicobacter pylori. The protein loss stopped within two weeks of the beginning of omeprazole and extensive edema disappeared. Four years later, the patient was still free from edema. Inflammatory involvement of the gastric mucosa probably caused protein losing in this patient. Recognition of this exsudative gastropathy is important because long term remission is obtained with omeprazole.

[Epidemiologic and virologic study of hepatitis C virus infections in Morocco]. / Etude épidémiologique et virologique des infections par le virus de l'hépatite C au Maroc.

OBJECTIVES: We prospectively studied 783 consecutive Moroccan patients to define: 1) the prevalence of anti-hepatitis C virus (HCV) antibody (Ab), 2) the prevalence of other viral infections: HBs Ag, anti-HAV IgM, anti-HGV, HGV RNA, 3) the risk factors of spreading HCV infection, and 4) the distribution of HCV genotypes. RESULTS: 60/783 (7.7%) patients had anti-HCV Ab (48 H/12 F), 26 (3.3%) HBs Ag, and 3 (0.3%) IgM anti-HAV. Anti-HGV Ab was found in 11/60 (18.3%) anti-HCV positive patients, and 6/38 (15.8%) anti-HCV negative patients. 2/22 (9%) serum anti-HCV positive and anti-HGV negative patients were positive for HGV RNA. The 60 HCV positive patients rarely had other viral infections: 3 (5%) HBs Ag, 11 (18.3%) anti-HGV positive, 2 (9%) HGV RNA positive, and none had anti-HBc, IgM anti-HAV, or anti-HIV. HCV positive patients had more often undergone transfusion of blood products (21.7 vs 5.5%; P < 0.0001), and dental treatment (55% vs 8.3%; p < 0.0001). Patients with anti-HCV Ab frequently had hepatitis lesions on liver biopsy, i.e. chronic active hepatitis (n = 44) or cirrhosis (n = 16). HCV RNA was positive in 45/60 (75%) anti-HCV positive patients. HCV genotypes were: 1b (n = 21, 47%), 2a/2c (n = 13, 29%), 1a (n = 6, 13%), et 3 (n = 1, 2%). CONCLUSIONS: In our Moroccan population, the prevalence of HCV was high (7.7%). Other viral infections (HBV, HAV, HGV) were rare.

[Post-infectious systemic vasculitis: recovery without corticotherapy]. / Vascularites systémiques post-infectieuses: guérison sans corticothérapie.

UNLABELLED: In the most cases the causes of systemic vasculitis are unknown and treatment is symptomatic (corticosteroids often associated with immunosuppressive agents). We report three cases of systemic vasculitis associated with infections for which dramatic improvement was observed without cortico-therapy (in two patients). CASE REPORT 1: A previously overweight 72-year-old woman was admitted because of a one-year history of fever, fourteen kilogram weight loss, vascular purpura, and polyneuropathy. Abnormal laboratory values included inflammatory syndrome [erythrocyte sedimentation rate (ESR): 80mm/first hour, thrombocytosis: 500,000/microliter, hypereosinophilia (1200/microliter) and positive perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCA) [anti-myelo-peroxydase antibodies: 30 U (normal < 7)]. Neuromuscular biopsy showed necrotizing vasculitis involving small and medium arteries. Further studies revealed a florid diverticulosis of the colon and no other severe visceral involvement. Treatment was started then with sigmoidectomy. Within six weeks her general condition improved dramatically without corticotherapy: regression of all systemic manifestations, the ESR normalized, and p-ANCA became negative. Ten months later she was still asymptomatic. CASE REPORT 2: An 50-year-old-man developed a progressive fifteen-kilogram weight loss (within 2 months), severe polyneuropathy of all four limbs. His ESR was 120 mm/first hour, and C-reactive protein 200 mg/l. Neuromuscular biopsy showed necrotizing vasculitis affecting small vessels in the nerve and no immune deposits. Stomatologic examination revealed a multiple foci of dental infections. The extraction of all these foci of infections associated with antibiotics improved dramatically all systemic manifestations (within eight weeks), once more without corticotherapy. Eight months later the patient remained asymptomatic. CASE REPORT 3: A 30-year-old-woman was admitted because of five-week history of fever, myalgias, polyarthritis, and cutaneous nodules in her limbs. Abnormal laboratory values included inflammatory syndrome, proteinuria of 0.7 g/day, and a significant rise in Chlamydia trachomatis antibodies titres from 1/64 to 1/256 over a 5 week period. She had a previous history of genital condyloma. The prednisone initialed (0.5 mg/kg/day) twelve days prior to admission was gradually reduced (stopped within 2 months) and treatment with doxycycline (200 mg/day) was initiated. Within six weeks of antibacterial treatment we assisted to a total regression of the initial clinical manifestations and laboratory values became normalized. Ten months later she remained asymptomatic. CONCLUSION: In systemic vasculitis, investigations in a search of foci of infections are of dual interest: possible etiologic agent like our case reports (strong evidence for an infectious association) and, from a therapeutic perspective, we must identify the microbes behind vasculitis syndromes, since treatment with corticosteroids may have serious consequences if the patient has an active infectious disease.

[Neurological manifestations of Behçet's disease]. / Manifestations neurologiques de la maladie de Behçet.

The neurological complications of Behçet's Disease are observed in 5 to 35 percent of cases depending of series. They included vascular and central nervous system manifestations. Vascular involvement is dominated by cerebral venous thrombosis marked by benign intracerebral hypertension. Prognosis is favourable with steroids and anticoagulation. Arterial involvement (thrombosis or aneurysm) are seldomly observed but increasingly with angio-MRI. Parenchymal involvement is dominated by meningoencephalitis eventually associated with fever. Myelitis and cranial nerve palsy are seldomly encountered. Cerebrospinal fluid is abnormal with lymphocytosis or pleiocytosis. MRI has a high sensitivity with hypersignals in the brainstem, basal ganglia, internal capsule and thalamus. Prognosis of central nervous system involvement is severe. Initially recovery is frequent, but severe impairment occurs due to relapse. In our experience, therapy including steroids, immunosuppressive drugs and colchicine improve short term and long term prognosis due to significant reduction of relapse in patients with good observance.

[Spinal cord involvement revealing systemic sarcoidosis]. / Sarcoïdose systémique révélée par une localisation médullaire.

Spinal neurosarcoidosis is rare (0.43 p. 100 of all sarcoidosis) and can be the initial manifestation of the disease. A 43-year-old right handed African man developed a progressive dorsal neck pain, slowly worsened paresthesia weakness in the legs and a gait disturbance. Magnetic resonance imaging (MRI) scan of the cervical and thoracic spinal cord (sagittal T(1)- weighted image) revealed diffuse enlargement of the cord from C2 to T7 with intense intramedullary enhancement from C2 to T3 after administration of contrast material on sagittal T(1)- weighted image. Cranial MRI scan was normal. Radiographs of the chest revealed bilateral symmetric hilar mediastinal lymphadenopathy with no pulmonary infiltrates. Bronchial biopsy demonstrated non caseating granulomas with langerhans giant cells. The serum angiotensin converting enzyme level was elevated. The patient received corticosteroid with good progressive response. His neurologic symptoms improved markedly and twenty months post-treatment MRI showed no abnormality on enhanced T(1)- weighted images. Two years later he had no relapse. Only 6 to 10 p. 100 of patients with neurosarcoidosis have spinal cord involvement, which may account for the first clinical manifestation of the disease. Most patients with neurosarcoidosis have associated extraneurologic abnormalities. The diagnosis is supported usually by extraneurologic biopsies. Spinal cord biopsy needs to be considered on case-by-case basis.

Postvaccine vasculitis: a report of three cases. / Vascularites postvaccinales: à propos de trois observations.

INTRODUCTION: Vaccines may be responsible for adverse effects, mainly local fugitive and benign reactions. However, few cases of systemic vasculitis have been described. We report three new cases, suggesting the responsibility of vaccination in starting or reactivating systemic vasculitis. EXEGESIS: We report two cases in a 64- and a 68-year-old woman with polymyalgia rheumatica and temporal arteritis after influenza and tetanus vaccination respectively, and one case in a 30-year-old man with periarteritis nodosa after hepatitis B vaccination. CONCLUSION: Knowledge of such complications deserve to be expanded in order to: 1) avoid re-immunisations which are likely to result in more serious consequences; 2) avoid aggravation or reactivation of a vasculitis; and 3) control serology before hepatitis B vaccination in all persons at risk of HBV infection.

[Vascular manifestations of Behçet's syndrome associated with solitary ulcerations and resolved with immunosuppressants]. / Manifestations vasculaires de type angio-Behçet associées à une aphtose monopolaire isolée et résolutives sous immunosuppresseurs.

INTRODUCTION: Behçet's disease is a systemic inflammatory disorder characterized by vasculitis. Its typical features are recurrent oral and genital ulcerations with uveitis. Although vascular lesions are not listed among the criteria for diagnosis of Behçet's disease, up to 25-35% of the patients develop complications in arterial and venous large vessels. EXEGESIS: We describe the case of a 45-year-old French man with Behçet-type vasculopathy. Though only one sign of Behçet's disease, i.e., oral ulcerations, was present, the patient had to undergo emergency surgery three times. The postoperative treatment combined corticosteroids, azathioprine, and oral anticoagulants. Three years later no therapy failure was observed. CONCLUSION: On the basis of 1) recurrent aortic aneurysms, 2) large arterial and venous occlusive lesions, 3) superficial phlebitis, and 4) ulcerations of the aorta in macro- and microscopic examination of resected aortic walls, we concluded that the patient's life threatening vasculopathy was of the Behçet's type, even if several of the diagnostic features of Behçet's disease were lacking. Variations in clinical features of Behçet's disease are observed that might be due to hereditary traits, particularly to the genetic expression of an incomplete phenotype that would lead to the lack of typical clinical features.

[Autoimmune hepatitis and hepatitis C]. / Hépatites auto-immunes et infection par le virus de l'hépatite C.

From autoimmune hepatitis (AIH) classification which recognizes three types of AIH, we discuss the main relations between hepatitis C virus (HCV) infection and AIH. Type I AIH is associated with antinuclear and antismooth muscle antibodies, and with other autoimmune diseases. There is no relation between type I AIH and HCV. Type I anti-liver kidney microsome and anti-liver cytosol I antibodies represent the hallmark of type II AIH. Among type II AIH, two subgroups emerged: type IIa AIH (10-40%) are true AIH (sensitive to steroids but worsens with interferon alpha), whereas type IIb AIH (60-90%) appear as a particular form of HCV hepatitis. Type IIb AIH have a moderate activity, a low titer of autoantibodies, anti-GOR antibodies but never anti-liver cytosol I, no sensitivity to steroids but are sensitive to interferon alpha. The hallmark of type III AIH are anti-cytosol antibodies, but these AIH have the same characteristics as type I AIH. The classification between true AIH (I, IIa, III) or "pseudo-AIH" due to HCV infection has major therapeutic implications. Steroids or immunosuppressive treatments are effective in type I, IIa and III AIH but have no efficacy in type IIb AIH. Alpha interferon has an efficacy in type IIb AIH, but it has no efficacy and may even worsen hepatitis in type I, IIa and III AIH.

[Severe gastrointestinal hemorrhage secondary to diffuse angiodysplasia: efficacy of estrogen-progesterone treatment]. / Hémorragies digestives sévères secondaires à une angiodysplasie diffuse: efficacité du traitement estroprogestatif.

BACKGROUND: Vascular abnormalities are being reported with increasing frequency as a cause of major lower gastrointestinal hemorrhage in the elderly. They are occasionally very difficult to treat by conventional means. CASE REPORT: A 66-year-old white man with a history of type 2 diabetes mellitus, coronary artery disease, congestive heart failure, severe peripheral arterial occlusion disease and chronic renal insufficiency presented for five years recurrent major bleeding due to gastrointestinal angiodysplasia, requiring repeated transfusions. He was treated with efficacy using ethinyl-estradiol (30 micrograms) and norethisterone acetate (1 mg) given orally once daily. After six months of treatment, transfusion requirements fell to 0 unit and the patient's hemoglobin was stable at 13 g/dl. Attempts to stop hormone therapy (by the patient himself, without complaint of side effects) led to a fall in hemoglobin. CONCLUSION: Hormonal therapy should be considered when multiple degenerative mucosal vascular bleeding lesions are beyond the reach of therapeutic endoscopy leading to high transfusion needs and when surgical risk is unacceptably high.

[Polymyositis induced by tiopronine]. / Polymyosite induite par la tiopronine.

BACKGROUND: D-penicillamine-induced muscle disorders are well-known, tiopronine-induced disorders are less often reported. CASE REPORT: A 62-year-old patient, given tiopronine for rheumatoid arthritis, developed severe polymyositis with characteristic clinical and pathology features. The course was favorable after tiopronine withdrawal and substitution with methotrexate. DISCUSSION: Clinicians should be aware of the side-effects of tiopronine, particularly muscle disorders, and implement careful surveillance to achieve early diagnosis and appropriate therapy.